If you read this article last month you know we shared information about kidney disease. In that article, experts stressed controlling blood glucose levels and hypertension to make sure that our kidneys remain healthy.
There are many of these medications and here we will share their uses, side effects and reasons for prescribing each type. We do not include all of the side effects listed because no percentages are given and all side effects read, by definition, as scary.
If you need to protect your kidneys, please discuss any side effects with your physician who will be able to give you the real scoop. Now, when your physician suggests that you may want to start taking an anti-hypertensive, you will have information at your fingertips so that you can ask the questions you need answered.
When I went on an anti-hypertensive, it was suggested because I had had type 1 diabetes for more than 20 years and my physician had watched my blood pressure move up slightly during extreme exercise. We discussed the use of the medication which has the ability to protect renal function as well the necessity to keep my blood pressure at a more normal level. Having to take one more pill did not make me feel good.
To tell the truth, it was one more complication that I will have to continue to fight, but I began the battle before any renal damage and it is a pill, not dialysis, so knowing the medical implications, I continue on my regime. My blood work is normal and for now, all is as good as it’s going to get, living with diabetes.
Diuretics alone and taken with beta-blockers have been shown in large-scale clinical trials to decrease mortality in people with hypertension. In a double-blind, randomized controlled study in more than 30,000 men and women older than 55 years of age with hypertension and at least one risk factor for coronary heart disease, diuretic thiazide chlorthalidone was as effective as a calcium-channel blocker, amlodipine, or an ACE inhibitor, lisinopril, in preventing fatal coronary disease or a nonfatal myocardial infarction.
Many thiazide-type diuretics are used to treat hypertension. Hydrochlorothiazide and chlorthalidone are the most widely used These cost $6.00 and $13.80 per month. Metolazone and indapamide are thought to be effective in patients with impaired renal function when thiazides are not.( These medications run $30.00 -$36.00 and $12.00 for generic medication).
Many older patients can be treated with small doses of diuretics. Low doses are now used to enhance the effectiveness of other medications while minimizing adverse effects such as hypokalemia (abnormally low potassium concentration n the blood), hyperuricemia (excess uric acid in the blood), hypercholesterolemia, and hyperglycemia.
These medications can be used to treat hypertension in people with renal insufficiency as measured by creatinine clearance. In people without renal insufficiency, they may be less effective than thiazides in controlling hypertension. These medications range in cost from $9.00 to $22.00 per month. Side effects include dehydration, circulatory collapse, hypokalemia and others you can discuss with the prescribing physician.
Medications such as amiloride, spironolactone and triamterene are used with other diuretics to prevent or correct hypokalemia. These mediations can cause hyperkalemia, particularly in patients with renal impairment and those taking other medications that decrease aldosterone secretion such as ACE inhibitors and ARBs. Eplerenone, a selective aldosterone antagonist approved by the FDA but not yet marketed, may be tolerated better than spironolactone. They cost from $11.40 -29.70 per month.
Angiotension-converting enzyme (ACE) inhibitors are effective and well tolerated for the treatment of hypertension. They are somewhat less effective in black patients unless combined with a thiazide diuretic.
ACE inhibitors, unlike diuretics, do not cause hyperlipidemia or hyperglycemia, both of which are very important to those of us with diabetes. They have been shown to prolong survival in patients with heart failure or left ventricular dysfunction after a myocardial infarction, preserve renal function in people with type 1 diabetes, and reduce mortality in patients without heart failure or left cardiovascular dysfunction but at high risk for cardiovascular events.
They may also preserve renal function in patients with non-diabetic nephropathies. An ACE inhibitor (ramipril) was found superior to a dihydropyridine calcium-channel blocker (amlodipine) in slowing progression to renal failure in black patients with hypertensive nephropathy. The most often side effects of ACE inhibitors are cough and rarely angioedema. They should not be taken in pregnancy. The average cost of these medications is $9.30 for a generic brand of an older medication to $34.50 for one that is still protected.
Angiotension Receptor Blockers (ARBs)
ARBs interfere with binding of angiotension II to AT1 receptors; they are effective in lowering blood pressure without causing cough. An ARB (irbesartan) delayed development of overt diabetic nephropathy in hypertensive patients with type 2 diabetes.
In diabetic patients who already have overt diabetic nephropathy, an ARB (irbesartan, losartan) slowed the progression of renal disease. In patients with hypertension and left ventricle hypertrophy, with or without diabetes, an ARB (losartan) decreased cardiovascular morbidity and mortality more than a beta blocker (atenolol).
Whether ARBs provide the same cardiac and renal protection as ACE inhibitors remains to be established. Like ACE inhibitors, ARBs may be less effective in black patients and should not be used during pregnancy. In patients who have had angioedema with ACE inhibitor, ARBs should be used with caution Side effects are similar as those for ACE inhibitors except for the cough. Costs range from $30.60 to $44.40.
Beta-Adrenergic Blocking Drugs:
Beta-blockers are effective treatment of hypertension, but like Ace inhibitors and ARBs, may be less effective in black patients. A beta-blocker alone appears to lee effective than a diuretic alone for treatment of the elderly. One analysis of randomized trials of beta blockers found, contrary to a widely held belief, no increased risk of depressive symptoms and only small increased risks of fatigue and sexual dysfunction compared to placebo. These findings have been disputed.
Propranolol, timolol, nadolol, pindolol, penbutolol, and careolol are nonselective beta-blockers. In low doses, bisoprolol, atenolol, metoprolol, acebutolol, acebutolol and betaxolol are cardioselective, with a greater effect on cardiac (beta 1) adrenergic receptors than on beta 2-adrenergic receptors in bronchial and blood vessels. These drugs become less selective as dosage is increased, and even low doses may cause bronchospasm. They range in price from generic medications at $9.60 to $40.20 for some non-generic medications.
Pindolol, acebutolol, penbutolol, and careolol have intrinsic sympathomimetic activity (ISA). Beta-blockers with ISA can lower blood pressure with less decrease in heart rate at rest and may be preferred for patients who develop symptomatic brachycardia or postural hypotension with other beta-blockers. Beta-blockers without ISA are preferred in patients with angina or a history of myocardial infarction. The costs range from $19.80 to $46.20.
Labetalol combines nonselective beta blockage and minimal ISA with alpha-adrenergic receptor blockade. It decreases blood pressure more promptly than other beta blockers, is equally effective in black and white patients, and does not affect serum lipids. Carvedilol is a nonselective beta-blocker with alpha-blocking properties and no ISA. It is used for treatment of heart failure. These range from generic costs of $24.00 to $99.00.
Calcium-channel blockers cause vasodilatation with decreased peripheral resistance. The cardiac response to decreased vascular resistance is variable; with felodipine, nicardipine, nisoldipine and immediate-release nifedipine (dihydrpyridines) , as initial reflex tachycardia usually occurs, but isradipine, verapamil, diltiazem, sustained-release nifedipine and amlodipine generally cause little or no increase in heart rate.
Verapamil and diltiazem slow heart rate, can affect atrioventricular (AV) conduction and should be used with caution in parents also taking a beta-blocker. Short-acting calcium-channel blockers should not be used for treatment of hypertension. Two meta-analyses have suggested that the risks of coronary artery disease and heart failure are higher in patients treated with calcium-channel blockers compared to ACE inhibitors, beta-blockers and diuretics.
One study of patients with diabetes and hypertension found a higher risk of myocardial infarction with a calcium-channel blocker (nisoldipine) than with an ACE inhibitor (enalapril). In elderly patients with isolated systolic hypertension, treatment with a dihydropyridine calcium channel blocker (nitrendipine, not available in the US), sometimes with enalapril and/or hydrochlorothiazide added, reduced the rate of stroke compared to placebo. The price of using these medications go from a generic at $22.50 to $53.10.
Central Alpha-Adrenergic Agonists:
Drugs such as clonadine, guanabenz, guanfacine and methyldopa do not inhibit reflex responses as completely as sympatholytic drugs that act peripherally. They do, however, frequently cause sedation, dry mouth and impotence. They cost from $5.70 for generic medications to $46.95.
Alpha-Adrenergic Blocking Drugs:
Prazosin, terazosin and doxazosin cause less tachycardia than direct vasodilators but more frequent postural hypotension, especially after the first dose. Treatment of essential hypertension with doxazosin has been associated with an increased incidence of heart failure, compared to treatment with a diuretic; it is not known whether this will occur with prazosin or terazosin.
Alpha-blockers also provide symptomatic relief from prostatism in men, but may cause stress incontinence in women and postural hypotension in elderly patients. They cost from $6.90 for a generic drug to $57.90 for other generic medications.
Direct vasodilators frequently produce reflex tachycardia, but they rarely cause orthostatic hypotension. They should usually be given with a beta-blocker or a centrally-acting drug to minimize the reflex increase in heart rate and cardiac output, and with a diuretic to avoid sodium and water retention. They should be avoided in patients with coronary artery disease.
Hydralazine maintenance dosage should be limited to 200 mg a day to decrease the possibility of a lupus-like reaction. Minoxidil, a potent drug, rarely fails to lower blood pressure, but should be reserved for severe hypertension refractory to other drugs. These medications range from $8.40 to $24.60.
Peripheral Adrenergic Neuron Antagonists:
These drugs can cause troublesome adverse effects. Reserpine is an effective antihypertensive, but in doses higher than currently recommended it can cause severe depression. Guanadrel usually decreases cardiac output and may lower systolic pressure more than diastolic; postural and exertional hypotension occur commonly and are aggravated by vasodilatation caused by heat, exercise or alcohol. They range in cost from $8.70 for a generic to $56.40.
Drugs of choice should be fitted to individual patients. With the information provided here you can visit the specialist and have a very intelligent conversation about how to control your high blood pressure.
There is no substitute for a well trained physician who orders the correct tests and forms a relationship with you of trust and mutual respect. We would not recommend that you take this information as the end of your education, but rather as an invitation to learn more and take care of yourself to the best of your ability with the help of an excellent team of physicians. To that end, continue reading.
There are combination medications, as many patients need more than one drug to control hypertension. These are convenient medications and help with compliance. In general, professionals suggest that a thiazide might be a good choice for an initial treatment of hypertension.
In special categories of patients, another type of medication may offer advantages. ACE inhibitors should be considered in patients with left ventricular dysfunction or heart failure. An ACE inhibitor or ARB would be a good choice for patients with hyperlipidemia or diabetes particularly those with nephropathy. A beta-blocker may be the best choice for hypertensive patients with angina pectoris or migraine, for those who have had a myocardial infarction, and for some patients with heart failure.
Remember reading the beginning of this article that some medications did not work as well for black patients as others. Diuretics and calcium-channel blockers are more effective than beta-blockers, ACE inhibitors or ARBs in black patients. A diuretic with or without a beta-blocker, or a long-acting dihydropyridine calcium-channel blocker alone, is preferred in older patients with systolic hypertension.
Diuretics and ARBs are the best tolerated antihypertensive medications. Beta-adrenergic blockers, ACE inhibitors and calcium-channel blockers also generally have mild adverse effects, but some experts suggest the latter should be reserved for patients who do not respond to or cannot tolerate diuretics, beta-blockers, ACE inhibitors or ARBs.
One final thought come across when reading about medications and hypertension. That is that even when drugs are individualized, people respond differently. For that reason, your medication may be changed, or more than one may be needed to control high blood pressure.
Here at www.blogdiabetes.com we do not give medical advice to our readers. We do hope that this information will help you make the choice to treat your high blood pressure. We all know from reading the What’s Hot articles each month that the long-term complications of not controlling our diabetes and high blood pressure can lead to long-term complications, which can make our lives more difficult.